Leg Swelling

Name: Ben Davies

Age: 68 years old

Date of Birth: 20th November 1956

Occupation: Retired salesman

"I am in so much pain in my left leg and its all swollen up as well, I can barely move it!"

• Site: My left lower leg

• Onset: Only around 30 minutes ago

• Character: It’s very painful, worse than when I first came in with the fracture. It now looks like its swollen as well which it wasn’t

• Radiation: Just all around the left lower leg

• Assoc Sx: I can’t move my leg at all because of the pain. If asked specifically - No numbness or tingling. Looks quite red.

• Timing: It’s just happened over the last half hour

• Exacerbating Factors: Trying to move it

• Relieving Factors: The nurses gave me some morphine which didn’t touch the pain

• Pain Scale: It’s a 10/10 now

• Recent illness: None.

• Recent trauma: Just the car accident I came in with, they said I broke my tibia.

• Recent travel: None.

• Previous episodes: Never experienced this before.

• Ideas: "I dont know what it is but the pain is really bad”

• Expectations: “What’s going on?"

• Concerns: “Something is definitely wrong, I wasn’t even in this much pain when I broke my bones."

• Bowel habits: Nil

• Urinary habits: Nil

• Appetite: Same as usual.

• Sleep: Same as usual

• Weight: No change 

• Pain in the chest/abdomen: None

• Headaches: None

• Fever: None

Previous hospital admissions: None

Previous surgeries: None

Medical conditions: T2DM, COPD, obesity, Hypertension, prev ischaemic heart disease

Medications:

• Amlodipine, ramipril, bisoprolol, metformin, aspirin

Allergies:

• None.

Nothing really

• Smoking: Current smoker, about 15 per day

• Alcohol: Couple of beers on the weekends

• Recreational drugs: Never

• Diet: Usually microwaveble food

• Exercise: Not really

• Ill contacts: No one around me was recently ill

• Home: Lives alone in flat

• Active Daily Living: Family and neighbours come in to help. I do shopping online

• Occupation: Retired hotel receptionist